Basic Information
| Provider Information | |||||||||
| NPI: | 1235247123 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KWEE | ||||||||
| FirstName: | LILY | ||||||||
| MiddleName: | SIOELI | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1019 PACIFIC AVE STE 300 | ||||||||
| Address2: | ATTN CREDENTIALING | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984024488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535974550 | ||||||||
| FaxNumber: | 2535974556 | ||||||||
| Practice Location | |||||||||
| Address1: | 10510 GRAVELLY LAKE DR SW | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984995036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535897188 | ||||||||
| FaxNumber: | 2532844384 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 11/12/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DE00007820 | WA | Y | Dental Providers | Dentist | General Practice | 1223G0001X | 4896 | NV | N | Dental Providers | Dentist | General Practice | 1223G0001X | 25070 | TX | N | Dental Providers | Dentist | General Practice | 1223G0001X | 4270 | KY | N | Dental Providers | Dentist | General Practice | 1223G0001X | DS038128 | PA | N | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 3815KW | 01 | REGENCE BLUESHIELD | OTHER | 5049069 | 05 | WA | MEDICAID | 7820WA | 01 | WA | WASHINGTON DENTAL | OTHER |